for Health and Dental Coverage and Help Paying Costs

Transcription

1 Member Booklet for Health and Dental Coverage and Help Paying Costs This is your member booklet for MassHealth, the Children s Medical Security Plan (CMSP), ConnectorCare Plans and Premium Tax Credits, and the Health Safety Net. March 2015 Commonwealth of Massachusetts Executive Office of Health and Human Services MassHealth Massachusetts Health Connector

2 MassHealth Disability Accommodation Ombudsman MassHealth has an ombudsman to help members and applicants with disabilities get the accommodations they need. This office can also provide personal assistance by explaining MassHealth processes and requirements and helping you fill out forms over the telephone. People who are deaf, hard of hearing, or speech disabled can call on VRS or by TTY. You can always get help in person at a MassHealth Enrollment Center (MEC). MassHealth can provide personal assistance by telephone or and can provide some publications in the following formats: large print electronic braille MassHealth Disability Accommodation Ombudsman 100 Hancock Street, 6th Floor Quincy, MA [email protected] TTY: (for people who are deaf, hard of hearing, or speech disabled) This Member Booklet is also available in other languages. Attention non U.S. citizens! See page 7 for important information about applying for MassHealth, CMSP, ConnectorCare Plans and premium tax credits, and the Health Safety Net.

3 INTRODUCTION 2 Section 1 How to get MassHealth, Children s Medical Security Plan (CMSP), ConnectorCare Plans and Premium Tax Credits, or the Health Safety Net How to apply for MassHealth, CMSP, ConnectorCare Plans and premium tax credits, or the Health Safety Net 4 Provisional eligibility 5 Hospital determined presumptive eligibility 6 The MassHealth card 6 Our decision and your right to appeal 6 What U.S. citizens/nationals need to know about applying for MassHealth and ConnectorCare Plans and premium tax credits 7 What non U.S. citizens need to know about applying for MassHealth or ConnectorCare Plans and premium tax credits 7 What non U.S. citizens need to know about applying for MassHealth Limited, MassHealth coverage for pregnant women, CMSP, and the Health Safety Net 7 What visitors need to know about applying 7 Section 2 Details about MassHealth coverage types and programs MassHealth Standard 8 MassHealth CommonHealth 11 MassHealth CarePlus 13 MassHealth Family Assistance 14 MassHealth Small Business Employee Premium Assistance 16 MassHealth Limited 16 Children s Medical Security Plan 18 Section 3 Massachusetts Health Connector 19 Section 4 The Health Safety Net Section 5 Applications and privacy Confidentiality and fair treatment Authorized representative 24 Permission to share information 25 How we use your social security number 25 Section 6 How income is counted Who is counted in your household for MassHealth and the Health Safety Net 26 Who is counted in your household for ConnectorCare Plans and premium tax credits 27 Modified Adjusted Gross Income (MAGI) 27 Section 7 Premiums and copays Copay and premium information for American Indians/Alaska Natives 29 MassHealth/CMSP premiums 29 MassHealth Copayments 32 Section 8 Other things you need to know Choosing a health plan and a doctor 33 MassHealth and other health insurance 33 Prior approval 34 Choosing and enrolling in a Medicare prescription drug plan 34 Out-of-pocket expenses 34 Out-of-state emergency treatment 34 MassHealth members turning age If you or members of your household are in an accident 34 Recovery against estates of certain members who die 35 Signing up to vote 35 Giving correct information 35 Reporting changes 35 Section 9 U.S. citizenship and immigration rules U.S. citizenship and immigration rules 36 U.S. Citizenship/National Status Requirements for MassHealth and ConnectorCare Plans and Premium Tax Credits Identity Requirements for MassHealth, ConnectorCare Plans and Premium Tax Credits, and the Health Safety Net 40 Section 10 Where to get help 42

4 2 INTRODUCTION You must be a resident of Massachusetts to get any kind of health care coverage. This means you actually live in Massachusetts and are not temporarily visiting here. This booklet makes it easier for you to understand health coverage available in Massachusetts. Please keep your booklet. It contains important information you may want to look up about health benefits. This booklet answers important questions that you may have about how to get health care benefits under MassHealth or the Massachusetts Health Connector. If you have any questions after reading this booklet, call a MassHealth Enrollment Center at (TTY: for people who are deaf, hard of hearing, or speech disabled). MassHealth provides health care benefits to certain lowand medium-income people living in Massachusetts. MassHealth offers these benefits to you directly or by paying part or all of your other health insurance premiums. In addition to MassHealth and related MassHealth programs, health care benefits are also provided through the Massachusetts Health Connector, as described on pages 3 and in this booklet. This booklet describes benefits for persons who are younger than age 65 and who are not living in nursing homes or other long-term-care facilities. There are some basic rules for getting MassHealth. Even if you or your household already have other health insurance (See MassHealth and other health insurance on page 33 of this booklet.), you may be eligible if your household Modified Adjusted Gross Income (MAGI) is low or medium. (See page 28 of this booklet for a chart that shows the income limits.) MassHealth offers different types of coverage based on whether you are a parent living with your children younger than age 19, or you are an adult caretaker relative living with children younger than age 19 to whom you are related by blood, adoption, or marriage, or are a spouse or former spouse of one of those relatives, and you are the primary caretaker of these children when neither parent is living in the home, or you are younger than age 19, or you are a young adult aged 19 or 20, or you are pregnant, or you are an adult aged 21 through 64, or you are disabled, or you work for a small employer, or you are HIV positive, or you have breast or cervical cancer. This booklet also describes benefits for certain persons aged 65 or older if they are parents or caretaker relatives

5 Visit us online at MAhealthconnector.org 3 of children younger than age 19, or are disabled and working 40 or more hours a month or are currently working and have worked at least 240 hours in the six months immediately before the month of the application, or are certain disabled immigrant children younger than age 19 who live in nursing homes or other long-term-care facilities.* * If you are aged 65 or older and are not described above, or if you are any age and applying for benefits that cover nursing home or similar care and are not described above, you should call us at one of the telephone numbers on pages to find out about other benefits that you may be able to get. To get MassHealth, the Children s Medical Security Plan (CMSP), ConnectorCare Plans and premium tax credits, or the Health Safety Net, you must fill out an application, which is included in an application packet. If you do not have an application packet and would like to get an application, call one of the telephone numbers listed on pages You can submit your application in any of the following ways. Sign on to your account at MAhealthconnector.org. You can create an online account if you do not already have one. Mail your filled-out, signed application to Health Insurance Processing Center P.O. Box 4405 Taunton, MA Fax your filled-out, signed application to Call the MassHealth Customer Service Center at (TTY: for people who are deaf, hard of hearing, or speech disabled) or MA ENROLL ( ). Visit a MassHealth Enrollment Center (MEC) to apply in person. See the Member Booklet for Health and Dental Coverage and Help Paying Costs for a list of MEC addresses. We have tried to make the application easy for you to fill out. Be sure to read all instructions before you begin. You must fill out the application and sign it. If any of the attached application supplements apply to you or any of your household members, you must also fill out and send them back with your filled-out application. MassHealth uses state and federal rules when it decides if you or your household members are eligible for either MassHealth or ConnectorCare Plans and premium tax credits. These rules are explained in this booklet. If you are eligible, you will get the most complete coverage that you qualify for. MassHealth and the Massachusetts Health Connector provide health care benefits through the following coverage types and programs. MassHealth Coverage Types MassHealth Standard MassHealth CommonHealth MassHealth CarePlus MassHealth Family Assistance MassHealth Small Business Employee Premium Assistance MassHealth Limited MassHealth Program Children s Medical Security Plan (CMSP) The rules for each coverage type and program are described in this booklet. The type of MassHealth coverage you may get may depend on your immigration status. (See U.S. citizenship and immigration rules on pages ) The Massachusetts Health Connector The Massachusetts Health Connector is the state s marketplace for health and dental insurance. The Health Connector can help you and your household shop for and enroll in insurance plans from leading health and dental insurers in the state. You can also find out through the Health Connector if you qualify for any programs that help you pay for health insurance premiums and lower your out-of-pocket health care costs. Programs through the Health Connector that can help you pay for health insurance include premium tax credits, ConnectorCare insurance plans, and cost sharing reductions. For more information about programs through the Health Connector and who can qualify for them, see pages in this Member Booklet. The Health Safety Net The Health Safety Net (HSN) pays Massachusetts acute hospitals and community health centers for certain health care services provided to low-income patients (Massachusetts residents with Modified Adjusted Gross Income (MAGI) household income at or below 400% of the federal poverty level).

6 4 SECTION 1 How to get MassHealth, Children s Medical Security Plan (CMSP), ConnectorCare Plans and Premium Tax Credits, or the Health Safety Net Apply faster online! Go to: MAhealthconnector.org. You will get results quickly. You can create a secure online account where you can see copies of notices and get important news fast. To apply in person, you can go to any one of the four following enrollment centers listed below. Do not send an application to any of these enrollment centers. MassHealth Enrollment Center Spruce Street Chelsea, MA MassHealth Enrollment Center 333 Bridge Street Springfield, MA MassHealth Enrollment Center 21 Spring Street, Suite 4 Taunton, MA MassHealth Enrollment Center 367 East Street Tewksbury, MA How to apply for MassHealth, CMSP, ConnectorCare Plans and premium tax credits, or the Health Safety Net 1. You can apply for benefits in several ways: online, by filling out a paper application, in person at a MassHealth Enrollment Center or authorized hospital, or by telephone. To apply by telephone, call MassHealth Customer Service at (TTY: for people who are deaf, hard of hearing, or speech disabled). By applying online, you can submit your application immediately, have much of your information proved electronically through data matches (thus eliminating the need to submit paper documents), and have your eligibility determined much faster. If you fill out a paper application, be sure to read the instructions. When it is filled out, send or fax it to Health Insurance Processing Center Fax: P.O. Box Taunton, MA We use the information collected on the online and paper applications, as well as proof of this information, to determine your eligibility for benefits, and if eligible, to make sure you get the most complete coverage you qualify for. We may also use it for other purposes related to the administration of the MassHealth program. 2. We will perform information matches with other agencies and information sources when an application is submitted, at annual review, and periodically to update or prove eligibility. These agencies and information sources may include, but are not limited to: the Internal Revenue Service, the Department of Homeland Security, the Social Security Administration, the Department of Revenue, and the Division of Unemployment Assistance. Income information will be obtained through an electronic data match. Income is considered proved if the income data received through an electronic data match is reasonably compatible with the income amount you stated on your application (the attested income amount). To be reasonably compatible, the attested income must be higher than the income from the data sources; or the attested income and the income from the data sources must be within a 10 percent range of each other. If electronic data sources are unable to prove attested information or are not reasonably compatible with attested information, additional documentation will be required from the applicant.

7 Visit us online at MAhealthconnector.org 5 3. We need the Modified Adjusted Gross Income (MAGI) for every person in your household. In most cases, this income can be proved through electronic data matches. If electronic data sources are not able to prove your income information, we will ask you for additional documentation. You will get a Request for Information notice that will list all the required forms of proof and the deadline for submitting them. (See pages for information about MAGI.) 4. You must give us a social security number (SSN) or proof that one has been applied for, for every household member who is applying, unless one of the following exceptions applies. You or any household member has a religious exemption as described in federal law. You or any household member is eligible only for a nonwork SSN. You or any household member is not eligible for an SSN. 5. To get the type of health care that gives the best coverage, we need to prove the U.S. citizenship/ national status or immigration status of every household member who is applying. (See pages for complete information about acceptable forms of proof.) We will conduct a data match with federal and state agencies to try to prove your U.S. citizenship/national status or immigration status. If electronic data sources are unable to prove your declared information, we will ask you for additional documentation. You will receive a Request for Information notice that will list all the required forms of proof and the deadline for submitting them. See pages for information about immigration status and eligibility for benefits. 6. As soon as we get the information we need, we will decide what benefits you are eligible for. We base our decision on state and federal law. 7. An individual s residency will be considered proven if the individual has self-declared to being a Massachusetts resident, and the residency has been confirmed by electronic data matching with federal or state agencies, or information services, or the individual has provided any of the following documents: A copy of the deed and record of the most recent mortgage payment (if the mortgage was paid in full, a copy of the property tax bill from the most recent year) A current utility bill or work order dated within the past 60 days A statement from a homeless shelter or homeless service provider School records (if school is private, additional documentation may be requested) Nursery school or day care records (if school is private, additional documentation may be requested) A Section 8 agreement A homeowners insurance agreement Proof of enrollment of custodial dependent in public school A copy of the lease AND record of the most recent rent payment If you cannot give us any of the documents listed above, you may submit an affidavit supporting residency signed under the pains and penalties of perjury. More specific information about MassHealth can be found in the MassHealth regulations at 130 CMR The application (in English, English large print, and Spanish) is also available online at To get interpreter services or a MassHealth Member Booklet in another language, call MassHealth Customer Service at (TTY: for people who are deaf, hard of hearing, or speech disabled). Provisional eligibility MassHealth provides benefits to eligible applicants based on self-attestation (except for disability, citizenship, and immigration status) during the provisional period.* Applicants must provide all outstanding eligibility forms of proof within 90 days of receipt of MassHealth s Request for Information Notice. Each applicant can only get one provisional eligibility approval in a 12-month period. MassHealth members will be required to enroll in a managed care plan during the provisional period, if otherwise mandatory to enroll. MassHealth members who have been assessed a premium will have to pay the premium during the provisional period. Premium Assistance will not be provided during the initial provisional period until all forms of proof have been submitted, and the health insurance investigation is complete. * You can also get benefits during a reasonable opportunity period, while you provide any required forms of proof of U.S. citizenship and identity or immigration status.

8 6 Hospital determined presumptive eligibility A qualified hospital may make presumptive eligibility determinations for its patients. Presumptive eligibility will be determined based on self-declared information. Qualified hospitals may determine presumptive eligibility for the following: 1. MassHealth Standard for children younger than age 19, for young adults aged 19 or 20, pregnant women, parents or caretaker relatives, individuals with breast or cervical cancer, individuals who are HIV positive, or independent foster care children up to age MassHealth CarePlus for adults aged MassHealth Family Assistance, if the individuals meet the categorical and financial requirements of MassHealth Family Assistance and are HIV positive, or children with incomes up to 150% of the federal poverty level (FPL) who have a nonqualified PRUCOL immigration status (See pages ) Only one hospital determined presumptive eligibility period per member is permitted within a 12-month timeframe, starting with the effective date of the initial presumptive eligibility period. An individual who has been eligible for MassHealth, Health Connector, or Health Safety Net benefits within the previous 12 months may not be determined presumptively eligible by a hospital. Benefits provided through the hospital presumptive eligibility process will begin on the date that the hospital determined presumptive eligibility and will continue until the end of the month following the month of the presumptive eligibility determination, if the individual has not submitted a complete application by that date, or an eligibility determination is made based upon the individual s submission of a complete application, if the complete application was submitted before the end of the month following the month of the presumptive eligibility determination. Note: MassHealth will not charge a premium during the hospital presumptive period. The MassHealth card Each eligible household member will get a MassHealth card or a CMSP card or both. You must show your card or cards to your doctor or other health care provider whenever you get medical care. If you have a MassHealth card and have other health insurance, be sure to show all cards. If you are eligible only for payment of health insurance premiums ( for example, some MassHealth Family Assistance members who only get premium assistance), you will not get a MassHealth card. People who get health insurance through a ConnectorCare plan will get a health insurance card from the health plan they choose. Those determined to be low-income for the purposes of the Health Safety Net (HSN) will not get a card. If you are eligible for HSN services, hospitals and community health centers will check to determine if they can get reimbursement for services provided to you and your household. Our decision and your right to appeal We will send you a notice to let you know if you can or cannot get one of the MassHealth coverage types or programs, or ConnectorCare Plans and premium tax credits, or the Health Safety Net. If you think that our decision is wrong, you have the right to ask for a fair hearing to appeal our decision. Notices have information that explains how to ask for a fair hearing and how much time you have to ask for one. See page 42 to find out where to send your fair hearing request. If you have questions about a MassHealth notice or how to ask for an appeal, call a MassHealth Enrollment Center at (TTY: for people who are deaf, hard of hearing, or speech disabled). If you have questions about a Health Connector appeal that is about services or premiums, call the Health Connector at If you have questions about a Health Safety Net grievance, call the Health Safety Net Customer Service Center at Health Safety Net determinations are conducted through MassHealth. More specific information about MassHealth can be found in the MassHealth regulations at 130 CMR , through , , and This booklet reflects the income standards in effect on March 1, 2015 and rules that are effective on January 1, For more information about hospital determined presumptive eligibility, see 130 CMR

9 What U.S. citizens/nationals need to know about applying for MassHealth and ConnectorCare Plans and premium tax credits Verification of U.S. citizenship/national status and identity is required for all U.S. citizens/nationals applying for MassHealth and ConnectorCare plans and premium tax credits. See pages for more information about proof of U.S. citizenship/national status and identity. If you need to provide proof, the most common forms of proof for both U.S. citizenship/national status and identity are a U.S. passport, a Certificate of U.S. Citizenship, a Certificate of U.S. Naturalization, or a document issued by a federally recognized American Indian tribe showing membership or enrollment in, or affiliation with, this tribe. U.S. citizenship/national status may also be proved with a U.S. public birth certificate or a Report of Birth Abroad of a U.S. Citizen. Identity may also be proved with a state driver s license containing the individual s photo, a government issued identity card containing the individual s photo, or a U.S. military ID card. For more detailed information about proving citizenship and identity, see pages We may be able to prove your identity through the Massachusetts Registry of Motor Vehicles records if you have a Massachusetts driver s license or a Massachusetts ID card. Once you give us proof of your U.S. citizenship/national status and identity, you will not have to give us this proof again. You must give us proof of identity for all household members who are applying. Seniors and disabled persons who get or can get Medicare or Supplemental Security Income (SSI), or disabled persons who get Social Security Disability (SSDI) do not have to give proof of their U.S. citizenship/national status and identity. A child born to a mother who was getting MassHealth on the date of the child s birth does not have to give proof of U.S. citizenship/national status and identity. (See pages for complete information about acceptable forms of proof.) For help getting proof, like a Massachusetts birth record or information about how to get a birth record from another state, please call MassHealth Customer Service at (TTY: for people who are deaf, hard of hearing, or speech disabled). What non U.S. citizens need to know about applying for MassHealth or ConnectorCare Plans and premium tax credits To get the type of health care that gives the best coverage, or to get a ConnectorCare plan and premium tax credits, satisfactory immigration status for each household member who is applying must be proved. Visit us online at MAhealthconnector.org We will perform information matches with federal and state agencies to prove immigration status. If electronic data sources are not able to prove an individual s declared information, we will ask for additional documentation. We will send a Request for Information notice that will list all the required forms of proof and the deadline for submitting them. Immigration status information is listed on pages 36-39, or go to the MassHealth Web site at What non U.S. citizens need to know about applying for MassHealth Limited, MassHealth coverage for pregnant women, CMSP, and the Health Safety Net Non U.S. citizens who are not eligible for an SSN or who do not have documentation of their immigration status may still qualify for MassHealth Limited, MassHealth coverage for pregnant women, CMSP, or the Health Safety Net. However, they do have to give us proof of their income; and proof of identity to be eligible for the Health Safety Net. Non U.S. citizens do not have to submit their immigration documents with the application if they are applying only for their children, but are not applying for any health coverage for themselves. If individuals do not have pay stubs or tax records, they can prove what their income is in other ways, like giving us a signed statement from their employer containing the gross (before taxes and deductions) pay and hours worked. Applications and the information on them will be kept confidential. This means that: names and addresses will not be sent to immigration enforcement officials; and we will not match information with other agencies if individuals do not have social security numbers. What visitors need to know about applying Individuals who are not Massachusetts residents are not eligible for MassHealth or other health care benefits that are funded by the Commonwealth of Massachusetts. Note: See page 44 for information about free and low-cost legal services. 7

10 8 SECTION 2 Details about MassHealth coverage types and programs This section of the booklet will help you learn about the coverage types and programs and if you might be eligible for any. For each of the coverage types and programs, this section tells you: Who can get benefits What the income standards are What health services are covered When coverage begins If you apply, you will get a notice from us. The notice will tell you if you can get benefits and when they will begin. We will give you the most complete coverage that you qualify for. MassHealth Standard This coverage type offers a full range of health care benefits. Who can get benefits You may be able to get MassHealth Standard if you are a resident of Massachusetts and are pregnant, or younger than age 19, or a young adult aged 19 or 20, or a parent living with your children younger than age 19*, or an adult caretaker relative living with children younger than age 19 to whom you are related and for whom you are the primary caretaker when neither parent is living in the home*, or younger than age 65 with breast or cervical cancer, or younger than age 65 and are HIV positive, or disabled according to the standards set by federal and state law. (This means you have a mental or physical condition that limits or keeps you from working for at least 12 months. MassHealth decides if you meet the disability standards.) or eligible based on special rules, which let you keep these benefits for up to 12 months after you have gone back to work or gotten a raise, no matter how much your new earnings are*, or a certain individual up to age 26 who was formerly in foster care (There is no income limit for these persons.), or a certain individual who is otherwise eligible for MassHealth CarePlus, has been determined to have special health care needs, and has chosen to be enrolled in MassHealth Standard, or younger than age 65 and getting services, or are on a waiting list to get services from the Department of Mental Health. * These benefits are also available for parents and caretaker relatives who are aged 65 or older. Income standards For information about income, see pages 26-28, Modified Adjusted Gross Income (MAGI). See the chart on page 28 for the federal poverty levels (FPLs).

11 For pregnant women and children younger than age one The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 200% of the federal poverty level. If you are pregnant, your unborn child (or children) is counted in your household size, which means there are at least two people in your household. For children aged one through 18 The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 150% of the federal poverty level. For young adults aged 19 or 20 The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 150% of the federal poverty level. For parents or caretaker relatives of children younger than age 19 The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 133% of the federal poverty level. For individuals with breast or cervical cancer The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 250% of the federal poverty level. For individuals who are HIV positive The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 133% of the federal poverty level. For individuals with Special Health Care Needs and Department of Mental Health individuals The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 133% of the federal poverty level. For disabled adults Your household income can be no more than 133% of the federal poverty level. For immigrants Certain immigrants cannot get MassHealth Standard, but they may be able to get health care benefits under other MassHealth coverage types and programs. This includes some immigrants who entered the United States on or after August 22, 1996, or who have lived in the United States under color of law. (See U.S. citizenship and immigration rules on pages ) Premiums and copayments Visit us online at MAhealthconnector.org Certain individuals with breast or cervical cancer who are eligible for MassHealth Standard may be charged a premium for their coverage. If you must pay a premium, we will tell you the amount and send you a bill every month. All other persons who are eligible for MassHealth Standard will not be charged a premium for their coverage. Certain adults may have to pay copayments for some medical services. For more information about premiums and copays, see pages Other health insurance If you have other health insurance, MassHealth may pay part of your household s health insurance premiums. See the section on MassHealth and other health insurance on pages MassHealth Premium Assistance under MassHealth Standard MassHealth may perform an investigation to determine if individuals who are receiving MassHealth Standard are either eligible for or have access to employersponsored health insurance in which MassHealth wants them to enroll. To find out more about the premium assistance rules under MassHealth Standard, see 130 CMR Covered services For MassHealth Standard, covered services include the ones listed below. There may be some limits. Your health care provider can explain them. Inpatient hospital services* Outpatient services: hospitals, clinics, doctors, dentists, family planning, and vision care Medical services: lab tests, X rays, therapies, pharmacy services, eyeglasses, hearing aids, medical equipment and supplies, adult day health, and adult foster care (For more information about choosing and enrolling in a Medicare prescription drug plan, see page 34.) Behavioral health (mental health and substance abuse) services Well-child screenings ( for children younger than age of 21): including medical, vision, dental, hearing, behavioral health (mental health and substance abuse), and developmental screens, as well as shots Long-term-care services at home or in a long-termcare facility, including home health services Transportation services** Quit-smoking services 9

12 10 * Certain restrictions can be found in the MassHealth regulations at 130 CMR ** Certain restrictions can be found in the MassHealth regulations at 130 CMR Note: For disabled adults who also get Medicare Part B, MassHealth will pay the Medicare premium, and if applicable, the coinsurance and deductibles. Important information for children and youth with significant mental health needs or serious emotional disturbance (SED) MassHealth offers certain behavioral health services for eligible children and youth younger than the age of 21 who are enrolled in MassHealth Standard or MassHealth CommonHealth. If your child is ineligible for MassHealth Standard and a behavioral health assessment or other evaluation shows that your child has significant mental health needs or a SED, he or she may be disabled and eligible for MassHealth CommonHealth. Additional services for children younger than the age of 21 Children, teens, and young adults younger than the age of 21 who are determined eligible for MassHealth Standard are also eligible for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services, which include all medically necessary services covered by Medicaid law. See 42 U.S.C. 1396a(a)(10), 1396d(a), and 1396d(r). This means that MassHealth pays for any medically necessary treatment that is covered by Medicaid law, if it is delivered by a provider who is qualified and willing to provide the service. If the service is not already covered by the child s MassHealth coverage type, the prescribing clinician can ask MassHealth for prior approval (PA) to determine if the service is medically necessary. MassHealth pays for the service if prior approval is given. A complete listing and a more detailed description of the services covered can be found in the MassHealth regulations at 130 CMR You may have copayments for some services. More information on copayments can be found in the MassHealth regulations at 130 CMR disability, your coverage may begin 10 calendar days before the date MassHealth gets your application. If you are eligible for premium assistance, you will begin to get payments in the month in which you are determined eligible for premium assistance, or in the month your health insurance deductions begin, whichever is later. Extended eligibility through Transitional Medical Assistance Certain MassHealth Standard members may be eligible for up to 12 months of benefits after their income has gone above 133% of the federal poverty level. MassHealth will give Transitional Medical Assistance (TMA) to parents and caretaker relatives (of children younger than age 19) and their children if the household income has gone up because a household member has gone back to work or gotten a raise. To get TMA, the household must give us proof of the new income and tell us when the increase began. Parents and caretaker relatives of children younger than age 19 who are aged 65 or older may also get TMA. Coverage begins If we get all needed information within 90 days, except for proof of disability, (or if you are a pregnant woman or a child or a young adult younger than age 21 who is eligible for provisional health care coverage as described on page 5), your coverage may begin 10 calendar days before the date MassHealth gets your application. If you are eligible for health care coverage based on a

13 MassHealth CommonHealth MassHealth CommonHealth offers health care benefits similar to MassHealth Standard to disabled adults and disabled children who cannot get MassHealth Standard. Who can get benefits You may be able to get MassHealth CommonHealth if you are a resident of Massachusetts and are: a disabled child younger than age 19, or a disabled young adult aged 19 or 20, or a disabled adult aged 21 or older who: works 40 hours or more a month or is currently working and has worked at least 240 hours in the six months immediately before the month of the application, or is younger than age 65 and is not working, or if working meets certain state and federal rules. MassHealth decides if you are disabled according to the standards set by federal and state law. For an adult, this generally means you have a mental or physical condition that severely limits your ability to work or to do certain activities for at least 12 months. Income standards If your household income is above 133% of the federal poverty level, you may have to pay a premium or meet a one-time-only deductible*. (This is explained on page 12.) See the chart on page 28 for the federal poverty levels. * Disabled individuals aged who are nonqualified PRUCOLs and have income at or below 150% of the federal poverty level will not be assessed a premium. Disabled adults aged 19 or older If your household income is above 150% of the federal poverty level, you will have to pay monthly premiums. The amount of the premium is based on your monthly income, as it compares to the federal poverty level, your household size, and if you have other health insurance. If you must pay a premium, we will tell you the amount and send you a bill every month. For more information about MassHealth/CMSP premiums, see pages Premiums and copayments Based on your income, you may be charged a premium. See pages Certain adults may have to pay copayments for some medical services. Other health insurance Visit us online at MAhealthconnector.org If you have other health insurance, MassHealth may pay part of your household s health insurance premiums. See the section on MassHealth and other health insurance on pages Covered services For MassHealth CommonHealth, covered services include the ones listed below. There may be some limits. Your health care provider can explain them. Inpatient hospital services* Outpatient services: hospitals, clinics, doctors, dentists, family planning, and vision care Medical services: lab tests, X rays, therapies, pharmacy services, eyeglasses, hearing aids, medical equipment and supplies, adult day health, and adult foster care (For more information about choosing and enrolling in a Medicare prescription drug plan, see page 34.) Behavioral health (mental health and substance abuse) services Well-child screenings ( for children younger than the age of 21): including medical, vision, dental, hearing, behavioral health (mental health and substance abuse), and developmental screens, as well as shots Long-term-care services at home or in a long-termcare facility, including home health services Transportation services** Quit-smoking services * Certain restrictions can be found in the MassHealth regulations at 130 CMR ** Certain restrictions can be found in the MassHealth regulations at 130 CMR Important information for children and youth with significant mental health needs or serious emotional disturbance (SED) MassHealth offers certain behavioral health services for eligible children and youth younger than the age of 21 who are enrolled in MassHealth Standard or MassHealth CommonHealth. If your child is ineligible for MassHealth Standard and a behavioral health assessment or other evaluation shows that your child has significant mental health needs or a serious emotional disturbance (SED), he or she may be disabled and eligible for MassHealth CommonHealth. 11

14 12 Additional services for children younger than age of 21 Children, teens, and young adults younger than age of 21 who are determined eligible for MassHealth CommonHealth are also eligible for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services, which include all medically necessary services covered by Medicaid law. See 42 U.S.C. 1396a(a)(10), 1396d(a), and 1396d(r). This means that MassHealth pays for any medically necessary treatment that is covered by Medicaid law, if it is delivered by a provider who is qualified and willing to provide the service. If the service is not already covered by the child s MassHealth coverage type, the prescribing clinician can ask MassHealth for prior approval (PA) to determine if the service is medically necessary. MassHealth pays for the service if prior approval is given. A complete listing and a more detailed description of the services covered can be found in the MassHealth regulations at 130 CMR You may have copayments for some services. More information on copayments can be found in the MassHealth regulations at 130 CMR Coverage begins If we get all needed information within 90 days, except for proof of disability, (or if you are a pregnant woman or a child or a young adult younger than age 21 who is eligible for provisional health care coverage as described on page 5), your coverage may begin 10 calendar days before the date MassHealth gets your application. If you are eligible for health care coverage based on a disability, your coverage may begin 10 calendar days before the date MassHealth gets your application. If you are eligible for premium assistance, you will begin to get payments in the month in which you are determined eligible for premium assistance, or in the month your health insurance deductions begin, whichever is later. The one-time-only deductible Certain disabled adults whose income is too high to get MassHealth Standard and who are not working at least 40 hours a month or who have not worked at least 240 hours in the six months immediately before the month of the application must meet a one-time-only deductible before getting MassHealth CommonHealth. The deductible is the amount that a household s income is higher than MassHealth s deductible income standard for a six-month period. MassHealth will tell you if you must meet a deductible to get MassHealth CommonHealth. You will be told the amount of the deductible. To meet the deductible, you must have medical bills that equal or are more than the deductible amount. You may use the bills of any household member including yourself, your spouse, and your children younger than age 19 to meet your deductible. You are responsible for paying these bills. You cannot use bills or portions of bills that are covered by other health insurance. Medical bills that may be used to meet a deductible include the cost of health insurance premiums for your household over the six-month period, unpaid bills you got before or during the deductible period, and bills that were paid during the deductible period. The deductible period begins 10 calendar days before the date that MassHealth gets your application and ends six months after that date. If you submit bills to meet a deductible, the medical coverage date also begins 10 calendar days before the date MassHealth gets your application. A more detailed description of the MassHealth eligibility requirements, including premium schedules, can be found in the MassHealth regulations at 130 CMR through More details about the one-time-only deductible can be found at 130 CMR The deductible income standard Family Size Standard 1 $542 2 $670 3 $795 Example $1,991 monthly income before taxes and deductions for a household of two - $670 income standard for a household of two $1,321 excess income 6 six-month period $7,926 deductible amount In this example, a deductible is met when the household has medical bills that are not covered by any other health insurance and the bills total $7,926.

15 MassHealth CarePlus MassHealth CarePlus offers a broad range of health care benefits to adults who are not otherwise eligible for MassHealth Standard. Who can get benefits You may be able to get MassHealth CarePlus if you are a resident of Massachusetts and a U.S. citizen or qualified noncitizen and you are an adult aged 21-64, and you are not eligible for MassHealth Standard. Income standards The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 133% of the federal poverty level. See the chart on page 28 for the federal poverty levels. Copayments There are no premiums for MassHealth CarePlus. Certain adults may have to pay copayments for some medical services. Other health insurance If you have other health insurance, MassHealth may pay part of your household s health insurance premiums. See the section on MassHealth and other health insurance on pages Covered services For MassHealth CarePlus, covered services include the ones listed below. There may be some limits. Your health care provider can explain them. Inpatient hospital services* Outpatient services: hospitals, clinics, doctors, dentists, vision care, and family planning Medical services: lab tests, X rays, therapies, pharmacy services, eyeglasses, hearing aids, and medical equipment and supplies Behavioral health (mental health and substance abuse) services Home health services Transportation services** Quit-smoking services * Certain restrictions can be found in the MassHealth regulations at 130 CMR ** Certain restrictions can be found in the MassHealth regulations at 130 CMR Some of the services not covered Visit us online at MAhealthconnector.org The following are examples of services not covered when you are enrolled in a health plan through MassHealth CarePlus: Day habilitation services Personal care services Private duty nursing services Long-term nursing facility services A complete listing and a more detailed description of the services covered can be found in the MassHealth regulations at 130 CMR If you need these services, you may have special health care needs and be eligible to choose to enroll in MassHealth Standard. Please call MassHealth Customer Service. Coverage begins If we get all needed information within 90 days, except for proof of disability, your coverage may begin 10 calendar days before the date MassHealth gets your application. If you are eligible for premium assistance, you will begin to get payments in the month in which you are determined eligible for premium assistance, or in the month your health insurance deductions begin, whichever is later. Individuals with Special Health Care Needs Individuals who have special health care needs may be able to get more benefits. Special health care needs include if you have a medical, mental health, or substance abuse condition that limits your ability to work or go to school; need help with daily activities, like bathing or dressing; regularly get medical care, personal care, or health services at home or in another community setting, like adult day care; or are terminally ill. If you have special health care needs, please call MassHealth at (TTY: for people who are deaf, hard of hearing, or speech disabled). You can tell us at any time if you have special health care needs, including if your health changes in the future. If you tell us about your special health care needs, you may choose to enroll in MassHealth Standard. MassHealth Standard covers all the same benefits 13

16 14 as MassHealth CarePlus, as well as additional health benefits like community long-term services and supports such as personal care attendants, adult day health programs, and more. Your health plan options in MassHealth Standard may be different than those offered in MassHealth CarePlus. There are no monthly premiums for either MassHealth CarePlus or MassHealth Standard. And with MassHealth Standard, your copays will be the same as what you pay in MassHealth CarePlus. If you move to MassHealth Standard, there may be some additional steps needed to get some of the added benefits that MassHealth Standard provides. For example, MassHealth may need additional information or may need to check to make sure the benefits are necessary and appropriate for you. Your doctor and MassHealth Customer Service can help explain these additional steps to you. Even if you have special health care needs, you can choose to stay enrolled in MassHealth CarePlus instead of moving to MassHealth Standard. If you want to stay in MassHealth CarePlus, you do not have to do anything else. MassHealth Family Assistance Who can get benefits You may be able to get MassHealth Family Assistance if you are a resident of Massachusetts, and are not eligible for MassHealth Standard. For children A child younger than age 19 is eligible if the Modified Adjusted Gross Income (MAGI) of the MassHealth MAGI household is at or below 300% of the federal poverty level and is a U.S. citizen/national or lawfully present immigrant. A child younger than age 19 is eligible if the Modified Adjusted Gross Income (MAGI) of the MassHealth MAGI household is at or below 300% of the federal poverty level and is a nonqualified PRUCOL. (See pages ) For young adults A young adult aged 19 or 20 is eligible if the Modified Adjusted Gross Income (MAGI) of the MassHealth MAGI household is at or below 150% of the federal poverty level and is a nonqualified PRUCOL. (See pages ) For adults An adult is eligible if the Modified Adjusted Gross Income (MAGI) of the MassHealth MAGI household is at or below 300% of the federal poverty level and is a nonqualified PRUCOL, and does not have access to employer-sponsored insurance that is considered affordable (meets the Minimum Essential Coverage (MEC) requirements under section 1401 of the Patient Protection and Affordable Care Act (ACA)). An adult who is HIV positive is eligible if the Modified Adjusted Gross Income (MAGI) of the MassHealth MAGI household is greater than 133%, but at or below 200% of the federal poverty level and is a U.S. citizen/national or a qualified noncitizen. A disabled adult is eligible if the household income is at or below 100% of the federal poverty level and is a qualified noncitizen barred, a nonqualified individual lawfully present, or a nonqualified PRUCOL. A certain adult is eligible who gets Emergency Aid to the Elderly, Disabled and Children (EAEDC).

17 Visit us online at MAhealthconnector.org 15 Premiums and copayments Based on your income, you may be charged a premium. See pages Certain adults may have to pay copayments for some medical services. Other health insurance If you have other health insurance, MassHealth may pay part of your household s health insurance premiums. See the section on MassHealth and other insurance on pages How you get your benefits If you are enrolled with your employer s health insurance, MassHealth may be able to help you pay for this insurance in one of two ways: your employer will reduce the amount withheld from your paycheck for health insurance by the amount of your premium assistance benefit, or you will get a monthly check for the amount of your premium assistance benefit. Covered services Persons enrolled in a health plan through MassHealth Family Assistance get the applicable services listed below. There may be some limits. Your health care provider can explain them. Inpatient hospital services* Outpatient services: hospitals, clinics, doctors, dentists, family planning, and vision care Medical services: lab tests, X rays, therapies, pharmacy services, eyeglasses, hearing aids, and medical equipment and supplies Home health services Behavioral health (mental health and substance abuse) services Well-child screenings ( for children under the age of 21): including medical, vision, dental, hearing, behavioral health (mental health and substance abuse), and developmental screens, as well as shots Ambulance services (emergency only) Quit-smoking services * Certain restrictions can be found in the MassHealth regulations at 130 CMR Some of the services not covered The following services are examples of services not covered when you are enrolled in a health plan through MassHealth Family Assistance. Day habilitation services Personal care services Private duty nursing services Nursing facility services A complete listing and a more detailed description of the services covered can be found in the MassHealth regulations at 130 CMR Coverage begins If we get all needed information within 90 days, except for proof of disability, (or if you are a pregnant woman or a child or a young adult younger than age 21 who is eligible for provisional health care coverage as described on page 5), your coverage may begin 10 calendar days before the date MassHealth gets your application. If you are eligible for health care coverage, your coverage may begin 10 calendar days before the date MassHealth gets your application. If you are eligible for premium assistance, you will begin to get payments in the month in which you are determined eligible for premium assistance, or in the month your health insurance deductions begin, whichever is later.

18 16 MassHealth Small Business Employee Premium Assistance Who is eligible MassHealth offers premium assistance to uninsured adults with income between 133% and 300% of the federal poverty level who work for small employers, and are ineligible for any other MassHealth coverage type. These individuals must be ineligible to get premium tax credits through the Health Connector because they have access to qualifying employer-sponsored insurance. Eligibility requirements You may be eligible to get MassHealth Small Business Employee Premium Assistance if you are a resident of Massachusetts and are a citizen or qualified noncitizen, are aged 19 or older, have income greater than 133%, but no more than 300% of the federal poverty level, are ineligible for any other MassHealth coverage type, are ineligible to get premium tax credits through the Health Connector because you have access to employer-sponsored insurance that is considered affordable (meets the Minimum Essential Coverage (MEC) requirements under section 1401 of the Patient Protection and Affordable Care Act (ACA)), work for an employer with 50 or fewer full-time employees, have an offer of employer-sponsored insurance for which your premium contribution is greater than the state s affordability schedule, but the cost of an individual plan is less than 9.5% of your household income, and have not enrolled in your employer s insurance in the six months before the date of application or, in 2014 only, are a former Insurance Partnership member. Enrollment cap MassHealth may limit the number of individuals who can be enrolled in Small Business Employee Premium Assistance. When MassHealth sets such a limit, applicants will be placed on a waiting list when their eligibility has been determined. When MassHealth is able to open enrollment for Small Business Employee Premium Assistance, MassHealth will process the applications in the order they were placed on the waiting list. To find out more about the MassHealth Small Business Employee- Premium Assistance, see the regulations at 130 CMR MassHealth Limited This coverage type provides emergency health services to people who, under federal law, have an immigration status that keeps them from getting more services. (See pages for the U.S. citizenship and immigration rules.) Who can get benefits You may be able to get MassHealth Limited if you are a resident of Massachusetts and are pregnant, or younger than age 19, or a young adult aged 19 or 20, or an adult aged 21-64, or a parent living with your children younger than age 19*, or an adult caretaker relative living with children younger than age 19 to whom you are related and for whom you are the primary caretaker when neither parent is living in the home*, or disabled according to the standards set by federal and state law. This means you have a mental or physical condition that limits or keeps you from working for at least 12 months. MassHealth decides if you meet the disability standards. * These benefits are also available for parents and caretaker relatives who are aged 65 or older. Income standards For information about income, see pages 26-28, Modified Adjusted Gross Income (MAGI). See the chart on page 28 for the federal poverty levels. For pregnant women and children younger than age one The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 200% of the federal poverty level. If you are pregnant, your unborn child (or children) is counted in your household size, so there are at least two people in your household. Children younger than age one who meet these standards may also get services through the Children s Medical Security Plan. (See page 18.) For children younger than age one through 18 The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 150% of the federal poverty level. These children may also get services through the Children s Medical Security Plan. (See page 18.)

19 For young adults younger than age 19 or 20 The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 150% of the federal poverty level. For parents or caretaker relatives of children younger than age 19 and adults aged The Modified Adjusted Gross Income (MAGI) of your MassHealth MAGI household can be no more than 133% of the federal poverty level. For disabled adults Your household income can be no more than 133% of the federal poverty level. Covered services For MassHealth Limited, covered services include the ones listed below. You can get care only for medical emergencies (conditions that could cause serious harm if not treated). Inpatient hospital emergency services including labor and delivery Outpatient hospital emergency services, and emergency visits to emergency rooms Certain services provided by doctors and clinics outside of a hospital Pharmacy services used to treat an emergency medical condition Ambulance transportation for an emergency medical condition Note: The Health Safety Net may be able to pay for certain services not covered by MassHealth Limited when services are received at Massachusetts acute hospitals and community health centers. (See Section 4: The Health Safety Net on pages ) Visit us online at MAhealthconnector.org A more detailed description of the services or benefits included for each MassHealth coverage type can be found in the MassHealth regulations at 130 CMR Some of the services not covered Nonemergency medical services, including care and services related to an organ transplant procedure Coverage begins If you are eligible, your health care coverage may begin 10 calendar days before the date MassHealth gets your application, if we get all needed information within 90 days. Pregnant MassHealth Limited members are eligible through the end of their pregnancy and for 60 days postpartum. A more detailed description of the MassHealth eligibility requirements can be found in the MassHealth regulations at 130 CMR through and

20 18 Children s Medical Security Plan The Children s Medical Security Plan (CMSP) provides health insurance for primary and preventive care for children and teenagers who do not have health care coverage. Eligibility for this program is determined by MassHealth. If you are eligible, you will get a separate CMSP card. Who can get benefits You may be able to get coverage through the Children s Medical Security Plan if you are a resident of Massachusetts and are younger than age 19, uninsured, and not eligible for enrollment in any MassHealth coverage type. However, you may be enrolled in both MassHealth Limited and CMSP. Income standards There is no income limit for CMSP. If your household MAGI is above 200% of the federal poverty level, you may have to pay a premium. For more information about MassHealth/CMSP premiums, see pages See the chart on page 28 for the federal poverty levels. Information about premiums can be found in the MassHealth regulations at 130 CMR Covered services For the Children s Medical Security Plan, covered services include the ones listed below. There may be some limits and copays. Your health care provider can explain them. Outpatient services including preventive and sick visits Outpatient mental health services and substance abuse treatment services up to 20 visits per fiscal year Outpatient surgery and anesthesia that is medically necessary for the treatment of inguinal hernia and ear tubes Prescription drugs up to $200 per state fiscal year Eye exams and hearing tests Durable medical equipment up to $200 per fiscal year. Asthma-, diabetes-, and epilepsy-related durable medical equipment may be available up to an additional $300 per state fiscal year Dental services maximum $750 per fiscal year (This includes exams, X rays, cleanings, fluoride treatment, sealants, fillings, extractions, full or partial root canals, crowns, and space maintainers.) (Frequency limits apply to certain dental services.) Coverage begins If you are eligible, your health care coverage begins on the date MassHealth makes your final eligibility determination. Enrollment cap MassHealth may limit the number of children who can be enrolled in CMSP. When MassHealth sets such a limit, applicants will be placed on a waiting list when their eligibility has been determined. When MassHealth is able to open enrollment for CMSP, MassHealth will process the applications in the order they were placed on the waiting list. Note: The Health Safety Net may be able to pay for certain services not covered by CMSP when services are received at Massachusetts acute hospitals and community health centers for enrolled children up to and including 400% of the federal poverty level. If the child s household income is above 200% of the federal poverty level and at or below 400% of the federal poverty level, an annual deductible based on income will apply. (See Section 4: The Health Safety Net on pages ) A more detailed description of the MassHealth eligibility requirements can be found in the MassHealth regulations at 130 CMR

21 SECTION 3 Massachusetts Health Connector The Massachusetts Health Connector (Health Connector) provides access to health and dental insurance plans for individuals, families, and small businesses. Visit us online at MAhealthconnector.org Generally, you can qualify to buy a health and/or dental insurance plan through the Health Connector if you meet the following requirements: you are a resident of Massachusetts, and you are a U.S. citizen/national, or are lawfully present in the United States, and you are not in prison. Health Connector Plans All of the health plans offered provide full health benefits, including visits to the doctor or hospital, and prescriptions. The Health Connector s plans are described below using metallic terms to make it easier for you to compare them. Platinum plans have the highest premium but the lowest copays and deductibles. Gold and Silver plans have lower premiums, but higher copays and deductibles. Bronze plans have the lowest premiums, but the highest copays and deductibles. Each health plan also has different doctors, hospitals, and other providers in its networks. Help paying for health insurance You may also qualify to buy a low-cost insurance plan and get additional savings from the federal and state government through the Health Connector. The following cost saving programs are available for people who shop for insurance through the Health Connector: Premium Tax Credits ConnectorCare plans Premium Tax Credits Premium tax credits are a way to lower the cost of your insurance premiums. The amount of your tax credit depends on your household size and income. You can find out whether you qualify for a tax credit, and how much the credit will be after submitting an application. If you qualify for a premium tax credit, you can choose to get this credit at the end of the year when you file your taxes. Or, you can use it on a monthly basis towards your insurance premiums. The tax credit will be sent directly to your insurance company so that you pay less each month. You may also be able to use some of the tax credit to buy dental insurance through the Health Connector. 19

22 20 You may qualify for premium tax credits if you have income that is between 100.1% and 400% of the federal poverty level (FPL). For example, a household of four with an income of up to $97,000 a year may qualify for premium tax credits. You may also qualify for tax credits if you are a lawfully present immigrant with an income that is at or below 100% of the FPL; are not able to buy health insurance through an employer that meets minimum value requirements and is affordable; or are not eligible for coverage under a governmentsponsored plan (such as, MassHealth, Medicare, and TRICARE); and file federal income taxes. What does Minimum Value mean? A health insurance plan meets the minimum value standard if it is designed to pay at least 60% of the total cost of medical services. Please contact your employer, plan administrator, or health insurer to find out if the plan meets minimum value requirements. How do I know if my employer s plan is affordable and meets Minimum Value standards? Minimum Value standards mean that the health plan will pay at least 60% of the total cost of medical services for a standard population. The other 40% of costs would be paid by members through deductibles, co-pays, and co-insurance. Most employer plans meet the Minimum Value standards. To find out if your employer s plan meets these standards, talk to your human resources department or the health plan. How do I know if my employer s plan is affordable? Under the Affordable Care Act (ACA), your employer s plan is considered affordable in 2015 if the lowest-cost plan that covers only the employee costs less than 9.56% of your household s income. Do not use the cost of a family plan, even if you need coverage for your whole family. The following steps will help you determine if the plan is affordable. A. Determine your household s Modified Adjusted Gross Income (MAGI) for Write that number down here: $ B. Find out what 9.56% of your monthly household income is. 1. Take the Modified Adjusted Gross Income you estimated in step A and multiply it by $ 2. Divide the amount in Number 1 by 12 $. This is 9.56% of your estimated monthly income for next year. C. Write down the lowest-cost monthly premium for employee-only coverage. $ (Ask your employer for this information.) Is this amount more than 9.56% of your income in Section B? If yes, insurance is not affordable to you. If no, insurance is affordable to you. Read across the row closest to your household s estimated income to see how much an affordable premium is. If your household income is: Insurance is affordable if the lowest cost plan to cover the employee only (not a family plan) costs less than: $5,000 $39 $10,000 $79 $15,000 $119 $20,000 $159 $25,000 $199 $30,000 $239 $35,000 $278 $40,000 $318 $45,000 $358 $ $398 $55,000 $438 $60,000 $478 $65,000 $517 $70,000 $557 $75,000 $597 $80,000 $637 $85,000 $677 $90,000 $717 $95,000 $756 $100,000 $796 To get tax credits, you need to file income taxes for the year when you got health benefits. If you are married, you need to file your income taxes jointly.

23 Visit us online at MAhealthconnector.org 21 ConnectorCare plans In addition to premium tax credits from the federal government, you may also be able to get help paying for health insurance from Massachusetts through a ConnectorCare health insurance plan. ConnectorCare plans are a set of health insurance plans with lower monthly premiums and lower outof-pocket costs. They are available for people whose income is at or below 300% of the FPL. If you qualify for a ConnectorCare plan, you will be able to get the most savings possible if you choose one of these plans for your health insurance. premium bill before its due date. Once you have chosen a plan and paid your first bill, your coverage will begin on the first day of the following month. Cost sharing reductions Cost sharing is the amount of money you pay when you get medical care. These costs may include copays and annual deductibles, and sometimes coinsurance. If you qualify for cost sharing reductions, your out-of-pocket costs will be lower when you get care. Cost sharing reductions are available for people with incomes that are at or below 250% of the FPL. Cost sharing reductions are only available if you are enrolled in a ConnectorCare plan. Special cost sharing for American Indians and Alaska Natives There are special cost sharing rules for American Indians and Alaska Natives. If you are an American Indian and you get services directly from an Indian Health Service Center, tribal or Urban Indian organization, or through the Contract Health Service program, you will not have to pay any out-of-pocket costs at the time you get care. You will also be able to enroll in or change health plans on a monthly basis throughout the year. American Indians and Alaska Natives with income at or below 300% of the FPL will not have to pay for cost sharing expenses, such as copays, deductibles, and coinsurance. Premiums If you have a monthly premium, it must be paid at least five business days before the first of the month. Generally, if you send your payment by the 20th of the month, it should be received in time. Coverage begins After you qualify for a health or dental insurance plan through the Health Connector, you must complete your enrollment before your coverage can begin. To finish enrolling, you must choose a medical or dental insurance plan and send payment for your first

24 22 SECTION 4 The Health Safety Net The Health Safety Net (HSN) pays Massachusetts acute hospitals and community health centers for certain health care services provided to low-income patients (Massachusetts residents with household income at or below 400% of the federal poverty level). Eligibility for the Health Safety Net is determined by MassHealth. Who can get benefits The Health Safety Net may be able to pay for certain services you receive from an acute hospital or a community health center if you are a resident of Massachusetts and you are uninsured or underinsured (your health insurance does not cover all medically necessary services). Income standards You must give us proof of your MAGI income for every person in your household. The Health Safety Net covers individuals with household MAGI at or below 400% of the federal poverty level. If your MAGI income is above 200% and at or below 400%, an annual deductible based on income may apply. The deductible is a certain amount of health care costs you are responsible for. Both paid and unpaid bills can count towards your deductible. Only services that the Health Safety Net can pay for will count towards your deductible. Private doctor and private lab or radiology bills do not count towards the deductible, even if you get these services in a hospital. Ask your provider which bills can count towards your deductible. Covered services For the Health Safety Net, services must be provided by a Massachusetts acute hospital or community health center. The Health Safety Net will generally pay for the same services that are covered by MassHealth Standard. The Health Safety Net pays for some pharmacy services, but you must fill your prescription at a pharmacy associated with the doctor who wrote your prescription. There may be some limits, so you should always check with a provider to see if they offer the service. You may be charged copays and deductibles. Some of the services not covered Some noncovered services are listed below. You should check with your provider to find out the full list of what is and is not covered. Physicians who are not employed by the hospital, even if they work at the hospital Ambulance services

25 Visit us online at MAhealthconnector.org 23 Lab charges that are not billed by a Massachusetts acute care hospital or community health center Radiology services that are not billed by a Massachusetts acute care hospital or community health center Durable medical equipment, except for crutches and canes provided during a medical visit Nonmedical services (social, educational, vocational) Nonmedically necessary services Experimental or unproven services A more detailed description of the services covered and any limitations can be found in the Health Safety Net regulations at 101 CMR Coverage begins If you are eligible, your Health Safety Net eligibility may begin up to six months before the date MassHealth gets your application, if we get all the needed information within 90 days. Ask your provider if you have retroactive Health Safety Net eligibility. Deductible income standard If your MAGI income is above 200% of the federal poverty level, you may be responsible for a deductible. A Health Safety Net deductible is calculated as 40% of the difference between the lowest MAGI in your Premium Billing Family Group and 200% of the federal poverty level. See pages Grievance process Patients may request that the Health Safety Net conduct a review of an eligibility determination, or of provider compliance with the Health Safety Net regulation. To file a grievance with the HSN, send a letter to: Health Safety Net Office Attn.: HSN Grievances 100 Hancock Street, 6th floor Quincy, MA The letter should include your name and address, and, if possible, information about the situation, the reason for the grievance, the provider s name (if a provider is involved), and any other relevant information. Questions about filing a grievance should be directed to the HSN Help Line at

26 24 SECTION 5 Applications and privacy Confidentiality and fair treatment MassHealth cannot discriminate against you because of race, color, sex, age, handicap, country of origin, sexual orientation, religion, or creed. MassHealth is committed to keeping the personal information we have about you confidential. All personal information MassHealth has about any applicant or member, including medical data, health status, and the personal information you give us during your application for and receipt of benefits is confidential. This information may not be used or released for purposes not related to the administration of MassHealth without your permission unless required by law or a court order. You can give us your written permission to use your personal health information for a specific purpose or share it with a specific person or organization. You can also give us your permission to share your personal information with your authorized representative or certified application counselor, if you have one, by filling out an Authorized Representative Designation Form or a Certified Application Counselor Designation Form. For more information about how MassHealth may use and share your information and what your rights are regarding your information, please review the MassHealth Notice of Privacy Practices. You can get a copy by calling the MassHealth Customer Service Center at (TTY: for people who are deaf, hard of hearing, or speech disabled) or by visiting Authorized representative An authorized representative is someone you choose to help you get health care coverage through programs offered by MassHealth and the Massachusetts Health Connector. You can do this by filling out the Authorized Representative Designation Form (ARD) or a similar designation form. An authorized representative may fill out your application or eligibility review forms, give proof of information given on these eligibility forms, report changes in your income, address, or other circumstances, get copies of all MassHealth or Health Connector eligibility or enrollment notices sent to you, and act on your behalf in all other matters with MassHealth or the Health Connector. An authorized representative can be a friend, family member, relative, or other person or organization of your choosing who agrees to help you. It is up to you to choose an authorized representative, if you want one. MassHealth or the Health Connector will not choose an authorized representative for you.

27 You must designate in writing on the Authorized Representative Designation Form or a similar designation document or authorization document the person or organization you want to be your authorized representative. In most cases, your authorized representative must also fill out this form or a similar designation document or authorization document. This form is included in the application packet, or you can call us, or visit to get one. Please see the instructions on the form for more details. An authorized representative can also be someone who is acting responsibly on your behalf if you cannot designate an authorized representative in writing because of a mental or physical condition, or has been appointed by law to act on your behalf or on behalf of your estate. This person must fill out the applicable parts of the Authorized Representative Designation Form or provide a similar designation document. If this person has been appointed by law to represent you, either you or this person must also submit to MassHealth or the Health Connector a copy of the applicable legal document stating that this person is lawfully representing you or your estate. This person may be a legal guardian, conservator, holder of power of attorney, or health care proxy, or if the applicant or member has died, the estate s administrator or executor. Permission to share information If you want us to share your personal health information, including sending copies of your eligibility notices, with someone who is not your authorized representative, you can do this by giving us written permission. We have forms you can use to do this. You can call us, or visit to get a copy of the appropriate form. Visit us online at MAhealthconnector.org We match the SSN of anyone in your household who is applying and anyone who has or who can get health insurance for any such persons with the files of agencies, including the following: Internal Revenue Service Social Security Administration Systematic Alien Verification for Entitlements (SAVE) Centers for Medicare & Medicaid Services (CMS) Registry of Motor Vehicles Department of Revenue Department of Transitional Assistance Department of Industrial Accidents Division of Unemployment Assistance Department of Veterans Services, Human Resource Division Bureau of Special Investigations Bureau of Vital Statistics (Department of Public Health). If MassHealth pays part of your health insurance premiums, MassHealth may add your SSN or the SSN of the policyholder in your household to the State Comptroller s vendor file. You or the policyholder in your household must have a valid SSN before you can get a payment from MassHealth. Files may also be matched with social service agencies in this state and other states, and computer files of banks and other financial institutions, insurance companies, employers, and managed care organizations. 25 How we use your social security number Unless one of the exemptions on page 5 applies, you must give us a social security number (SSN) or proof that one has been applied for, for every household member who is applying. MassHealth may require you to give us the SSN, if you can get it, of any person not applying who has or who can get health insurance that covers you or any member of your household. We use SSNs to check information you have given us. We also use them to detect fraud, to see if anyone is getting duplicate benefits, or to see if others (a third party ) should be paying for services.

28 26 SECTION 6 How income is counted Who is counted in your household for MassHealth and the Health Safety Net MassHealth determines household size or household composition at the individual member level in one of two ways. To calculate financial eligibility for an individual, a household will be constructed for each individual who is applying for or renewing coverage. Different households may exist within a single family, dependent on the family members familial and tax relationships to each other. Income of all household members forms the basis for establishing an individual s eligibility. A household s countable income is the sum of the MAGI-based income of every individual included in the individual s household with the exception of children and tax dependents who are not expected to be required to file a tax return. 1. MassHealth MAGI household composition. a. MassHealth will use the MassHealth MAGI household composition rules to determine members eligible for one of the following benefits. MassHealth Standard, except for disabled adults MassHealth CommonHealth for disabled children younger than age 19 MassHealth CarePlus MassHealth Family Assistance Small Business Employee Premium Assistance MassHealth Limited Children s Medical Security Plan b. The household consists of taxpayers not claimed as a tax dependent on his or her federal income taxes: If the individual expects to file a tax return for the taxable year in which an initial determination or renewal of eligibility is being made, and does not expect to be claimed as a tax dependent by another taxpayer, the household consists of the taxpayer, the taxpayer s spouse (if living with him or her), all persons who the taxpayer expects to claim as a tax dependent, and the number of expected children

29 individuals claimed as a tax dependent on federal income taxes: If the individual expects to be claimed as a tax dependent by another taxpayer for the taxable year in which an initial determination or renewal of eligibility is being made and who does not otherwise meet the Medicaid exception rules as described in 130 CMR , the household consists of the individual person claimed as a dependent, the dependent s spouse (if living with him or her), the taxpayer claiming the individual as a tax dependent, any of the taxpayer s tax dependents, and the number of expected children c. Household size must be determined in accordance with nontax filer rules if any of the following exceptions apply: individuals other than a spouse or a biological, adopted, or step child who expects to be claimed as a tax dependent by another taxpayer, individuals younger than 19 years of age who expect to be claimed by one parent as a tax dependent, and are living with both parents but whose parents do not expect to file a joint tax return, and individuals under 19 years of age who expect to be claimed as a tax dependent by a noncustodial parent. d. For an individual who neither files a federal tax return or is not claimed as a tax dependent on a federal tax return, or when any of the exceptions apply as described in 1.c. above, the household consists of the individual and if living with the individual: the individual s spouse, the individual s natural, adopted, and step children younger than age 19, individuals younger than 19 years of age, the individual s natural, adopted, and stepparents and natural, adoptive, and step siblings younger than age of 19, and the number of expected children Visit us online at MAhealthconnector.org 2. Disabled adult MassHealth household composition. a. MassHealth will use the Disabled Adult MassHealth household composition rules to determine members eligible for one the following benefits. MassHealth Standard for disabled adults aged MassHealth CommonHealth for disabled adults aged MassHealth CommonHealth for certain disabled young adults aged MassHealth Family Assistance for certain disabled individuals b. The household consists of the individual, the individual s spouse, the individual s natural, adopted and step children younger than age 19, and the number of expected children. Who is counted in your household for ConnectorCare Plans and premium tax credits The Health Connector determines household size or household composition by applying tax filing rules. The household consists of the primary taxpayer, the spouse, and all tax dependents. Additional tax filing requirements are the following. Married taxpayers are required to file jointly. Recipients of premium tax credits are required to file taxes for the year in which they receive credits. Modified Adjusted Gross Income (MAGI) Financial eligibility is based on Modified Adjusted Gross Income (MAGI). MAGI is the income reported on line 22 on the personal 1040 income tax return after the deductions from lines have been deducted. Then tax-exempt interest and foreign earned income exclusions are added back in. Countable Income MAGI methodology includes earned income, such as wages, salary, tips, commissions, and bonuses. MAGI methodology does not count pre-tax contributions to salary reduction plans (of up to $2,500 or $5,000 depending on filing status) for payment of dependent care, transportation, and certain health expenses. 27

30 28 Self-employment income is included in adjusted gross income, but the tax code allows deductions for various business-related travel and entertainment expenses (up to a limit), and business use of a personal home. If the deductions exceed the income earned from self-employment, the losses can be used to offset other income. An amount received as a lump sum is counted as income only in the month received. Exception: for plans through the Health Connector, income received as a lump sum is countable for the year in which it is received. Deductions The following are allowable deductions from countable income when determining MAGI: educator expenses; expenses for reservists; performance artist, or fee-based government officials; health savings account; moving expenses; self-employment taxes; self-employment retirement accounts; penalties on early withdrawal of savings; alimony paid to a former spouse; individual retirement accounts (IRAs); student loan interest; and higher education tuition and fees. Noncountable Income Scholarships, awards, or fellowship grants used for education purposes and not for living expenses* Distributions to American Indians and Alaska Natives (AI/AN)* Child support received Income received by a Transitional Assistance to Families with Dependent Children (TAFDC), Emergency Aid to the Elderly, Disabled and Children (EAEDC), or Supplemental Security Income (SSI) recipient Sheltered workshop earnings Nontaxable federal veterans benefits Certain income-in-kind Certain room and board income derived from persons living in the applicant s or member s principal place of residence Any other income that is excluded by federal laws other than the Social Security Act Income received by an independent foster care adolescent * Exception: for plans through the Health Connector, income received is countable income. Federal Poverty Levels (Monthly) Household Size 100% 5% 133% 150% 200% 250% 300% 400% 1 $981 $50 $1,305 $1,472 $1,962 $2,453 $2,943 $3,924 2 $1,328 $67 $1,766 $1,992 $2,655 $3,319 $3,983 $5,310 3 $1,675 $84 $2,227 $2,512 $3,349 $4,186 $5,023 $6,697 4 $2,021 $102 $2,688 $3,032 $4,042 $5,053 $6,063 $8,084 5 $2,368 $119 $3,149 $3,552 $4,735 $5,919 $7,103 $9,470 6 $2,715 $136 $3,610 $4,072 $5,429 $6,786 $8,143 $10,857 7 $3,061 $154 $4,071 $4,592 $6,122 $7,653 $9,183 $12,244 8 $3,408 $171 $4,532 $5,112 $6,815 $8,519 $10,223 $13,630 Additional Persons $347 $18 $462 $520 $694 $867 $1,040 $1,387 MassHealth updates the federal poverty levels each year based on changes made by the federal government. The income levels above reflect the standards as of March 1, 2015.

31 SECTION 7 Premiums and copays Visit us online at MAhealthconnector.org Copay and premium information for American Indians/Alaska Natives American Indians and Alaska Natives who have received or are eligible to receive a service from an Indian health care provider or from a non Indian health care provider through referral from an Indian health care provider are exempt from paying copays and premiums, and may get special monthly enrollment periods as MassHealth members. A more detailed definition of who is considered to be an American Indian or Alaska Native can be found in the MassHealth regulations at 130 CMR MassHealth/CMSP premiums MassHealth may charge a monthly premium to certain MassHealth members who have incomes above 150% of the federal poverty level. MassHealth may also charge a monthly premium to members of the Children s Medical Security Plan (CMSP) who have incomes at or above 200% of the federal poverty level. MassHealth and CMSP premium amounts are calculated based on a member s household MAGI and household size as described in the Premium Billing Family Group (PBFG) rules in Part B of this section. If you have to pay a monthly premium, MassHealth will send you a notice with the premium amount. You will also get a bill every month. If you do not pay your premium payments, your benefits may end. If MassHealth decides you must pay a premium for benefits, you are responsible for paying these premiums unless you tell MassHealth to close your case within 60 days from the date your eligibility was determined or a premium hardship waiver was approved. MassHealth may refer past due premium balances (delinquent accounts) to the State Intercept Program (SIP) for recovery. State Intercept Program regulations can be found at 815 CMR A. Premium Billing Family Groups (PBFG) 1. Premium formula calculations for MassHealth and CMSP premiums are based on the Premium Billing Family Group (PBFG). A premium billing family group consists of an individual, a couple two persons who are married to each other according to the laws of the Commonwealth of Massachusetts, 29

32 30 a family a family is defined as persons who live together, and consists of (a) a child or children younger than age 19, any of their children, and their parents, (b) siblings younger than age 19 and any of their children who live together even if no adult parent or caretaker relative is living in the home, or (c) a child or children younger than age 19, any of their children, and their caretaker relative when no parent is living in the home. 2. A child who is absent from the home to attend school is considered as living in the home. A parent may be a natural, step, or adoptive parent. Two parents are members of the same premium billing family group as long as they are both mutually responsible for one or more children who live with them. 3. MassHealth and CMSP premiums for children younger than age 19 with household income at or below 300% of the federal poverty level will have their premium amount determined using the lowest percentage of the federal poverty level of all children in the PBFG. If any child in the PBFG has a percentage of the federal poverty level at or below 150% of the federal poverty level, premiums for all children younger than age 19 in the PBFG will be waived. 4. MassHealth and CMSP premiums for children younger than age 19 with household income greater than 300% of the federal poverty level, and all premiums for young adults or adults are calculated using the individual s federal poverty level. B. Individuals within a PBFG that are approved for more than one premium billing coverage type When the PBFG contains members in more than one coverage type or program, including CMSP, who are responsible for a premium or required member contribution, the PBFG is responsible for only the higher premium amount or required member contribution. When the PBFG includes a parent or caretaker relative who is paying a premium for and is getting a ConnectorCare plan and premium tax credits, the premiums for children in the PBFG will be waived once the parent or caretaker relative has enrolled in and begun paying for a ConnectorCare plan. C. MassHealth Standard and Premium Formula for Members with Breast or Cervical Cancer The premium formula for MassHealth Standard members with breast or cervical cancer whose eligibility is described in 130 CMR is as follows. Standard Breast and/or Cervical Cancer Premium Formula % of Federal Poverty Level (FPL) Monthly Premium Cost Above 150% to 160% $15 Above 160% to 170% $20 Above 170% to 180% $25 Above 180% to 190% $30 Above 190% to 200% $35 Above 200% to 210% $40 Above 210% to 220% $48 Above 220% to 230% $56 Above 230% to 240% $64 Above 240% to 250% $72 D. MassHealth CommonHealth Premium Formulas 1. The premium formula uses age, income, and whether or not the member has other health insurance. 2. The premium formula for MassHealth CommonHealth members whose eligibility is described in 130 CMR is as follows. The full premium formula for children younger than age 19 with household income between 150% and 300% of the federal poverty level is provided below. CommonHealth Full Premium Formula Children younger than age 19 between 150% and 300% FPL % of Federal Poverty Level (FPL) Monthly Premium Cost Above 150% to 200% $12 per child ($36 PBFG maximum) Above 200% to 250% $20 per child ($60 PBFG maximum) Above 250% to 300% $28 per child ($84 PBFG maximum) The full premium formula for young adults aged 19 or 20 with household income above 150% of the federal poverty level, adults aged 21 and older with household income above 150% of the federal poverty level, and children with household income above 300% of the federal poverty level is provided below. The full premium is charged to members who have no health insurance and to members for whom the MassHealth agency is paying a portion of their health insurance premium.

33 CommonHealth Full Premium Formula Young Adults and Adults above 150% FPL and Children above 300% FPL Base Premium Above 150% FPL start at $15 Above 200% FPL start at $40 Above 400% FPL start at $202 Above 600% FPL start at $404 Above 800% FPL start at $646 Above 1,000% FPL start at $928 Additional Premium Cost Add $5 for each additional 10% FPL until 200% FPL Add $8 for each additional 10% FPL until 400% FPL Add $10 for each additional 10% FPL until 600% FPL Add $12 for each additional 10% FPL until 800% FPL Add $14 for each additional 10% FPL until 1,000% FPL Add $16 for each additional 10% FPL Range of Monthly Premium Cost $15 $35 $40 $192 $202 $392 $404 $632 $646 $912 $928 + greater The supplemental premium formula for young adults, adults, and children is provided below. A lower supplemental premium is charged to members who have health insurance that the MassHealth agency does not contribute to. Members getting a premium assistance payment from MassHealth are not eligible for the supplemental premium rate. CommonHealth Supplemental Premium Formula % of Federal Poverty Level (FPL) Premium Cost Above 150% to 200% 60% of full premium Above 200% to 400% 65% of full premium Above 400% to 600% 70% of full premium Above 600% to 800% 75% of full premium Above 800% to 1,000% 80% of full premium Above 1,000% 85% of full premium CommonHealth members who are eligible to get a premium assistance payment, as described in 130 CMR , that is less than the full CommonHealth premium will get their premium assistance payment as an offset to the CommonHealth monthly premium bill, and will be responsible for the difference. Visit us online at MAhealthconnector.org E. MassHealth Family Assistance Premium Formulas 1. The premium formula for MassHealth Family Assistance children whose eligibility is described in 130 CMR is as follows. Family Assistance for Children Premium Formula % of Federal Poverty Level (FPL) Monthly Premium Cost Above 150% to 200% $12 per child ($36 PBFG maximum) Above 200% to 250% $20 per child ($60 PBFG maximum) Above 250% to 300% $28 per child ($84 PBFG maximum) 2. The premium formulas for MassHealth Family Assistance HIV-positive adults whose eligibility is described in 130 CMR are as follows. The premium formula uses income and whether or not the member has other health insurance. The full premium formula for Family Assistance HIV-positive adults between 150% and 200% of the federal poverty level is charged to members who have no health insurance and to members for whom the MassHealth agency is paying a portion of their health insurance premium. The full premium formula is provided below. Family Assistance for HIV+ Adults Premium Formula % of Federal Poverty Level (FPL) Monthly Premium Cost Above 150% to 160% $15 Above 160% to 170% $20 Above 170% to 180% $25 Above 180% to 190% $30 Above 190% to 200% $35 The supplemental premium formula for Family Assistance HIV-positive adults is charged to members who have health insurance that the MassHealth agency does not contribute to. The supplemental premium formula is provided below. Family Assistance for HIV+ Adults Supplemental Premium Formula % of Federal Poverty Level (FPL) Monthly Premium Cost Above 150% to 200% 60% of full premium 31

34 32 The premium formula for MassHealth Family Assistance Nonqualified PRUCOL adults as described in 130 CMR is based on the MassHealth MAGI household income and the MassHealth MAGI household size as it relates to the federal poverty level income guidelines and the Premium Billing Family Group (PBFG) rules, as described in 130 CMR The premium formula is as follows. Family Assistance for Nonqualified PRUCOL Adults Premium Formula The premium formula can be found at 956 CMR F. Children s Medical Security Plan (CMSP) Premium Formula The premium formula for CMSP members whose eligibility is described in 130 CMR is as follows. CMSP Premium Schedule % of Federal Poverty Level (FPL) Monthly Premium Cost Greater than or equal to 200%, but less than or equal to 300.9% Greater than or equal to 301.0%, but less than or equal to 400.0% Greater than or equal to 400.1% $7.80 per child per month; family group maximum $23.40 per month $33.14 per premium billing family group per month $64.00 per child per month MassHealth Copayments Certain adults may have to pay copayments (copays) for some medical services. Pharmacy services. There is a $1 copay for certain prescriptions such as those used to treat hypertension, diabetes, and high cholesterol, and a $3.65 copay for most other prescriptions. Nonpharmacy services. There is a $3 copay for an acute inpatient hospital stay. The maximum amount MassHealth members have to pay is $250 for pharmacy services per calendar year; $36 for nonpharmacy services per calendar year; and 5% of the member s MAGI of the MassHealth MAGI household or the MassHealth Disabled Adult household per calendar quarter, including both copayments and any applicable premium payments. For more information about MassHealth copayments, see 130 CMR Members Exempted from Premium Payment The following members are exempt from premium payments. MassHealth members who have proved that they are American Indians or Alaska Natives who have received or are eligible to receive an item or service provided by the Indian Health Service, an Indian tribe, a tribal organization, an urban Indian organization, or by a non-indian health care provider through referral, in accordance with federal law MassHealth members with family group income at or below 150% of the federal poverty level Pregnant women Children younger than age one getting MassHealth Standard Children whose parent or guardian in the Premium Billing Family Group is eligible for a ConnectorCare plan and premium tax credits and has enrolled in and begun paying for a ConnectorCare plan.

35 SECTION 8 Other things you need to know Visit us online at MAhealthconnector.org Choosing a health plan and a doctor If you are approved for MassHealth Standard, CarePlus or Family Assistance, and do not have other health insurance, you must choose a doctor and a health plan through MassHealth. For Standard, CarePlus, and Family Assistance members without health insurance, you get coverage before you enroll in a health plan, but you are still required to enroll. Soon after we tell you that you can get MassHealth, we will send you information in an enrollment package that explains the MassHealth health plan choices you have and tells you how to enroll. You do not have to enroll in a health plan through MassHealth if you are eligible for MassHealth Limited; or any other MassHealth coverage type and have other health insurance. Choosing a health plan and doctor for yourself and your household is an important decision. If you need help making this decision, you can call the toll-free telephone number that is in the enrollment package and talk to a Customer Service Representative. The Customer Service Representative is trained to help you make the choice that is best for you and your household. If you are required to enroll in a health plan and you do not choose one, MassHealth will choose one for you. More information about choosing a health plan through MassHealth can be found in the MassHealth regulations at 130 CMR MassHealth and other health insurance To get and keep MassHealth, you must apply for and enroll in any health insurance that is available to you at no cost, including Medicare, enroll in health insurance when MassHealth determines it is cost effective for you to do so, or keep any health insurance that you already have. You must also give MassHealth information about any health insurance that you or a household member already have or may be able to get. We will use this information to decide if the services covered under your health insurance meet MassHealth s standards, and what we may pay toward the cost of your health insurance premium.

36 34 Under MassHealth, we may pay part of your health insurance premiums if your employer contributes at least 50% of the cost of the health insurance premiums; and the health insurance plan meets the Basic Benefit Level (that is if it provides comprehensive medical coverage to its members including MassHealthrequired health care benefits). Prior approval For some medical services, your doctor or health care provider has to get approval from MassHealth first. This is called prior approval. Medical services that are covered by Medicare do not need prior approval from MassHealth. Choosing and enrolling in a Medicare prescription drug plan If you are eligible for both Medicare and MassHealth, Medicare provides most of your prescription drug coverage through a Medicare prescription drug plan. This means you must choose and enroll in a Medicare prescription drug plan. If you do not choose a drug plan, Medicare will choose one for you. You may change plans at any time. Visit or call MEDICARE for information about how to choose and enroll in a Medicare prescription drug plan that is best for you. If you are enrolled in a Program of All-Inclusive Care for the Elderly (PACE) or Senior Care Options (SCO) plan, One Care Plan, a Medicare Advantage plan, a Medicare supplement (Medigap) plan, or have drug coverage through a current or former employer, be sure to contact your plan to find out more information about whether or not to enroll in a Medicare prescription drug plan. Out-of-pocket expenses In some cases, MassHealth can pay you back for medical bills that you paid before you got your MassHealth approval notice. We will do this if we denied your eligibility and later decided that the denial was incorrect; or you paid for a MassHealth covered medical service that you got before we told you that you would get MassHealth. In this case, your health care provider must pay you back and bill MassHealth for the service. The provider must accept the MassHealth payment as payment in full. Out-of-state emergency treatment MassHealth is a health care program for people living in Massachusetts who get medical care in Massachusetts. In certain situations, MassHealth may pay for emergency treatment for a medical condition when a MassHealth member is out of state*. If an emergency occurs while you are out of state, show your MassHealth card and any other health insurance cards you have, if possible. Also, if possible, tell your primary care provider or health plan within 24 hours of the emergency treatment. If you are not enrolled in a health plan through MassHealth, but instead get premium assistance, your other health insurance may also pay for emergency care you get out of state. * Per MassHealth regulation 130 CMR (B), MassHealth does not cover any medical services provided outside the United States and its territories. MassHealth members turning age 65 If you are or will soon be aged 65, and do not have children younger than age 19 living with you, you must meet certain income and asset requirements to keep getting MassHealth. We will send you a new form to fill out to give us the information we need to make a decision. If you can keep getting MassHealth, you will not get your medical care through a MassHealth managed care plan. Instead, you can get your medical care from any other MassHealth health care provider. If you or members of your household are in an accident If you or any members of your household are in an accident or are injured in some other way, and get money from a third party because of that accident or injury, you will need to use that money to repay whoever paid the medical expenses related to that accident or injury. 1. You will have to pay MassHealth for services that were covered by MassHealth or CMSP. If you are applying for MassHealth or CMSP because of an accident or injury, you will need to use the money to repay the costs paid by MassHealth for all medical services you and your household get. If you or any members of your household are in an accident, or are injured in some other way, after becoming eligible for MassHealth or CMSP, you will need to use that money to repay only the costs paid by MassHealth or CMSP for medical services provided because of that accident or injury.

37 2. You will have to pay the Massachusetts Health Connector or your health insurer for certain medical services provided. 3. You will have to pay the Health Safety Net for medical services reimbursed for you and any household members. You must tell MassHealth (for MassHealth and CMSP), your health insurer for ConnectorCare Plans and premium tax credits, or the Health Safety Net in writing within 10 calendar days, or as soon as possible, if you file any insurance claim or lawsuit because of an accident or injury to you or any household members who are applying for, or who already have, benefits. Third parties who might give you or members of your household money because of an accident or injury include the following: a person or business who may have caused the accident or injury; an insurance company, including your own insurance company; or other sources, like workers compensation. For more information about accident recovery, see the MassHealth regulations at 130 CMR and Chapter 118E of the Massachusetts General Laws. Recovery against estates of certain members who die MassHealth has the right to get back money from the estates of certain MassHealth members after they die. In general, the money that must be repaid is for services paid by MassHealth for a member after the member turned age 55. If a deceased member leaves behind a child who is blind, permanently and totally disabled, or younger than age 21, or a husband or wife, MassHealth will not require repayment while any of these persons are still living. If real property, like a home, must be sold to get money to repay MassHealth, MassHealth, in limited circumstances, may decide that the estate does not need to repay MassHealth. The property must be left to a person who meets certain financial standards, and who has lived in the property, without leaving, for at least one year before the now-deceased member became eligible for MassHealth. Also, certain income, resources, and property of American Indians and Alaska Natives may be exempt from recovery. Visit us online at MAhealthconnector.org In addition, when a member is eligible for both MassHealth and Medicare, MassHealth will not recover Medicare cost sharing benefits (premiums, deductibles, and copayments) paid on or after January 1, 2010, for persons who got these benefits while they were aged 55 or older. For more information about estate recovery, see the MassHealth regulations at 130 CMR and Chapter 118E of the Massachusetts General Laws. Signing up to vote This booklet includes information about voter registration. You do not need to register to vote to get health benefits. Giving correct information Giving incorrect or false information may end your benefits. It may also result in fines, imprisonment, or both. Reporting changes Once you start getting benefits, you must let us know about certain changes within 10 days of the changes or as soon as possible. These include any changes in income, household size, employment, disability status, health insurance, and address. If you do not tell us about changes, you may lose your benefits. MassHealth will perform information matches with other agencies and information sources when an application is submitted, at annual review, and periodically to update or prove eligibility. These agencies and information sources may include, but are not limited to: the Internal Revenue Service, the Social Security Administration, the Department of Revenue, and the Division of Unemployment Assistance. Income information will be obtained through an electronic data match. Income is considered proved if the income data received through an electronic data match is reasonably compatible with the income amount you stated on your application (the attested income amount). To be reasonably compatible the attested income must be higher than the income from the data sources: or the attested income and the income from the data sources must be within a 10 percent range of each other. If electronic data sources are unable to prove attested information or are not reasonably compatible with attested information, additional documentation will be required from the applicant. 35

38 36 SECTION 9 U.S. citizenship and immigration rules U.S. citizenship and immigration rules When deciding if you are eligible for benefits, we look at all the requirements described under each coverage type and program. We will try to prove your U.S. citizenship/ national status and immigration status using federal and state data services to decide if you may get a certain coverage type. U.S. Citizens/Nationals U.S. citizens/nationals may be eligible for MassHealth Standard, CommonHealth, CarePlus, Family Assistance, Small Business Employee Premium Assistance, or the Children s Medical Security Plan (CMSP). They may also be eligible for ConnectorCare Plans and premium tax credits or the Health Safety Net. Proof of citizenship and identity is required for all U.S citizens/nationals. A citizen of the United States is 1. an individual who was born in the United States or its territories, including Puerto Rico, the Virgin Islands, Guam, and the Northern Mariana Islands, except if born to a foreign diplomat and who otherwise qualifies for U.S. citizenship under 301 et seq. of the Immigration and Nationality Act (INA); 2. an individual born of a parent who is a U.S. citizen or who otherwise qualifies for U.S. citizenship under 301 et seq. of the INA; 3. a naturalized citizen; or 4. a national (both citizen and noncitizen national). (a) Citizen national. A citizen national is an individual who otherwise qualifies as a U.S. citizen under 301 et seq. of the INA. (b) Noncitizen national. A noncitizen national is an individual who was born in one of the outlying possessions of the United States, including American Samoa and Swain s Island, to a parent who is a noncitizen national. Non U.S. citizens To get the type of MassHealth that gives the most coverage, or to get a ConnectorCare plan and premium tax credits, satisfactory immigration status must be proved. MassHealth will perform information matches with state and federal agencies to prove immigration statuses. If electronic sources are unable to prove declared status, additional documentation will be required from the individuals. Non U.S. citizens do not have to submit their immigration documents with the application if they are applying only for their children, but are not applying for any benefits for themselves.

39 Visit us online at MAhealthconnector.org 37 Lawfully present immigrants The following are lawfully present immigrants. Qualified noncitizens People who meet one of the following statuses may be eligible for MassHealth Standard, CommonHealth, CarePlus, Family Assistance, or CMSP. They may also be eligible for benefits through the Health Connector or the Health Safety Net. There are two groups of qualified noncitizens: 1. People who are qualified regardless of when they entered the U.S. or how long they have had a qualified status. Such individuals are a. people granted asylum under section 208 of the INA; b. refugees admitted under section 207 of the INA; c. people whose deportation has been withheld under section 243(h) or 241(b)(3) of the INA, as provided by section 5562 of the federal Balanced Budget Act of 1997; d. veterans, their spouses, and their children (i) veterans of the United States Armed Forces with an honorable discharge not related to their noncitizen status; or (ii) Filipino war veterans who fought under U.S. command during WWII; or (iii) Hmong and Highland Lao veterans who are admitted for legal permanent residence (LPR) and who fought under U.S. command during the Vietnam War; or (iv) persons with noncitizen status on active duty in the U.S. Armed Forces, other than active duty for training; or (v) the spouse, unremarried surviving spouse, or unmarried dependent children of the noncitizen described in (i) through (iv) above; e. conditional entrants under section 203(a)(7) of the INA as in effect before April 1, 1980; f. people who entered as Cuban/Haitian entrants under section 501(e) of the Refugee Education Assistance Act of 1980; g. Native Americans with at least 50 percent American Indian blood who were born in Canada pursuant to section 289 of the INA or other tribal members born in territories outside of the United States pursuant to 25 U.S.C. 450b(e); h. Amerasians as described in section 402(a)(2)(A) (i)(v) of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996; i. victims of severe forms of trafficking, and spouse, child, sibling, or parent of the victim in accordance with the Victims of Trafficking and Violence Protection Act of 2000 (Public Law ) as amended; j. Iraqi Special Immigrants granted special immigrant status under Section 101(a)(27) of the INA, pursuant to section 1244 of Public Law or section 525 of Public Law ; or k. Afghan Special Immigrants granted special immigrant status under Section 101(a)(27) of the INA, pursuant to section 525 of Public Law People who are qualified based on having a qualified status identified at a below and who have satisfied one of the conditions listed at b below. Such individuals are a. people who have one or more of the following statuses: (i) people admitted for legal permanent residence (LPR) under the Immigration and Nationality Act (INA); or (ii) people granted parole for at least one year under section 212(d)(5) of the INA; or (iii) battered spouse, battered child, or child of battered parent or parent of battered child who meet the criteria of section 431(c) of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, 8 U.S.C. 1641; and also b. people who satisfy at least one of the following three conditions: (i) they have had a status listed in 2.a. above for five or more years (a battered noncitizen attains this status when the petition is accepted as establishing a prima facie case); (ii) they entered the U.S. before August 22, 1996, regardless of status at the time of entry, and have been continuously present in the U.S. until attaining a status listed in 2.a. above. For this purpose, an individual is deemed continuously present who has been absent from the U.S. for no more than 30 consecutive days or 90 nonconsecutive days before attaining a status listed in 2.a. above; or (iii) they also have or had a status listed in 1.a. through k. above.

40 38 Qualified noncitizens barred People who have a status listed under qualified noncitizens at 2.a. above (legal permanent resident, parolee for at least one year, or battered noncitizen) and who do not meet one of the conditions listed at 2.b. above, are qualified noncitizens barred. Qualified noncitizens barred, like qualified noncitizens, are lawfully present immigrants. People who are qualified noncitizens barred may be eligible for MassHealth Standard, CommonHealth, Family Assistance, Limited, or CMSP. They may also be eligible for benefits through the Health Connector and the Health Safety Net. Nonqualified individuals lawfully present People who are nonqualified individuals lawfully present and meet one of the following statuses may be eligible for MassHealth Standard, CommonHealth, Family Assistance, Limited, or CMSP. They may also be eligible for benefits through the Health Connector and the Health Safety Net. People who are nonqualified individuals lawfully present are not defined as qualified under the PRWORA of 1996, 8 U.S.C. 1641, but are lawfully present. Nonqualified individuals lawfully present are as follows. 1. People in a valid nonimmigrant status as otherwise defined in 8 U.S.C. 1101(a)(15) or otherwise defined under immigration laws as defined in 8 U.S.C. 1101(a) (17). 2. People paroled into the U.S. in accordance with 8 U.S.C. 1182(d)(5) for less than one year, except for an individual paroled for prosecution, for deferred inspection, or pending removal proceedings. 3. People who belong to one of the following classes: (a) granted temporary resident status in accordance with 8 U.S.C or 1255a, respectively; (b) granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. 1254a, and individuals with pending applications for TPS who have been granted employment authorization; (c) granted employment authorization under 8 CFR 274a.12(c); (d) Family Unity beneficiaries in accordance with section 301 of Public Law , as amended; (e) under Deferred Enforced Departure (DED) in accordance with a decision made by the President; ( f) granted Deferred Action status, except for applicants or individuals granted status under DHS Deferred Action for Childhood Arrival Process (DACA); (g) granted an administrative stay of removal under 8 CFR part 241; or (h) beneficiary of approved visa petition who has a pending application for adjustment of status. 4. People with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C. 1231, or under the Convention Against Torture who: (a) have been granted employment authorization; or (b) are under the age of 14 and have had an application pending for at least 180 days. 5. People who have been granted withholding of removal under the Convention Against Torture. 6. Children who have a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. 1101(a)(27)(J). Qualified noncitizens barred and nonqualified individuals lawfully present who are pregnant may be eligible for MassHealth Standard, a ConnectorCare plan and premium tax credits, or the Health Safety Net (HSN); children younger than age 19 may be eligible for MassHealth Standard, CommonHealth, Family Assistance, CMSP, a ConnectorCare plan and premium tax credits, or the HSN; young adults aged 19 or 20 may be eligible for MassHealth Standard, a ConnectorCare plan and premium tax credits, or the HSN; adults aged 21 or older and are parents or caretaker relatives may be eligible for MassHealth Limited, a ConnectorCare plan and premium tax credits, or the HSN; adults aged and are disabled may be eligible for MassHealth Family Assistance, Limited, a ConnectorCare plan and premium tax credits, or the HSN; or other adults aged may be eligible for MassHealth Limited, a ConnectorCare plan and premium tax credits, or the HSN. Nonqualified Persons Residing Under Color of Law (Nonqualified PRUCOLs) Nonqualified PRUCOLs are certain noncitizens who are not lawfully present. These individuals may be permanently residing in the United States under color of law as described in 130 CMR People who are nonqualified PRUCOLs and meet one of the following statuses may be eligible for MassHealth Standard, CommonHealth, Family Assistance, Limited, or CMSP.

41 Visit us online at MAhealthconnector.org 39 They may also be eligible for benefits through the Health Safety Net. 1. Noncitizens living in the United States in accordance with an indefinite stay of deportation 2. Noncitizens living in the United States in accordance with an indefinite voluntary departure 3. Noncitizens and their families who are covered by an approved immediate relative petition, who are entitled to voluntary departure, and whose departure the United States Department of Homeland Security (DHS) does not contemplate enforcing 4. Noncitizens granted voluntary departure by the DHS or an Immigration Judge, and whose deportation the DHS does not contemplate enforcing 5. Noncitizens living under orders of supervision who do not have employment authorization under 8CFR 274a.12(c) 6. Noncitizens who have entered and continuously lived in the United States since before January 1, Noncitizens granted suspension of deportation, and whose departure the DHS does not contemplate enforcing 8. Noncitizens with a pending application for asylum under 8 U.S.C or for withholding of removal under 8 U.S.C or under the Convention Against Torture who have not been granted employment authorization, or are under the age of 14 and have not had an application pending for at least 180 days 9. Noncitizens granted Deferred Action for Childhood Arrival status or have a pending application for this status 10. Noncitizens who have filed an application, petition, or request to obtain a lawfully present status that has been accepted as properly filed but who have not yet obtained employment authorization and whose deportation DHS does not contemplate enforcing 11. Any other noncitizens living in the United States with the knowledge and consent of the DHS, and whose departure the DHS does not contemplate enforcing. (These include persons granted Extended Voluntary Departure due to conditions in the noncitizen s home country based on a determination by the Secretary of State.) Nonqualified PRUCOLs who are pregnant may be eligible for MassHealth Standard, Family Assistance, or the HSN; children younger than age 19 may be eligible for MassHealth CommonHealth, Family Assistance, Limited, CMSP, or the HSN; young adults aged 19 or 20 may be eligible for MassHealth CommonHealth, Family Assistance, Limited, or the HSN; adults aged 21 or older who are parents or caretaker relatives may be eligible for MassHealth Family Assistance, Limited, or the HSN; and other adults aged 21 64, including disabled persons, may be eligible for MassHealth Family Assistance, Limited, or the HSN. Other noncitizens If your immigration status is not described above, you are considered an other noncitizen. You may be eligible for MassHealth Standard (if pregnant), Limited, CMSP, or the Health Safety Net. Note: People who were getting MassHealth, formerly known as Medical Assistance, or CommonHealth on June 30, 1997, may continue to get benefits regardless of immigration status if otherwise eligible. The eligibility of immigrants for publicly funded benefits is defined in the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, the federal Balanced Budget Act of 1997, and in various provisions of state law. For additional details, see the MassHealth regulations at 130 CMR

42 40 U.S. Citizenship/National Status Requirements for MassHealth and ConnectorCare Plans and Premium Tax Credits Identity Requirements for MassHealth, ConnectorCare Plans and Premium Tax Credits, and the Health Safety Net Proof of both U.S. Citizenship/National Status and Identity* * Exception: Seniors and disabled persons who get or can get Medicare or Supplemental Security Income (SSI), or disabled persons who get Social Security Disability (SSDI) do NOT have to give proof of their U.S. citizenship/national status and identity. A child born to a mother who was getting MassHealth on the date of the child s birth does not have to give proof of U.S. citizenship/national status and identity. The following are acceptable forms of proof of BOTH U.S. citizenship/national status AND identity. (No other documentation is required.): 1. a U.S. passport, including a U.S. Passport Card issued by the Department of State, without regard to any expiration date as long as this passport or Card was issued without limitation; or 2. a Certificate of U.S. Naturalization; or 3. a Certificate of U.S. Citizenship; or 4. a document issued by a federally recognized Indian tribe, as published in the Federal Register by the Bureau of Indian Affairs within the U.S. Department of the Interior, and identifies the federally recognized Indian Tribe that issued the document, identifies the individual by name and confirms the individual s membership, enrollment, or affiliation with the Tribe. These documents include, but are not limited to: a Tribal enrollment card, a Certificate of Degree of Indian Blood, a Tribal census document, and documents on Tribal letterhead issued under the signature of the appropriate Tribal official that meet the requirements of 130 CMR OR Proof of U.S. Citizenship/National Status Only If one of the documents that satisfies both citizenship and identity is not provided, the following documents may be accepted as proof of U.S. citizenship/national status only. A U.S. public birth certificate (including the 50 states, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, Swain s Island, or the Commonwealth of the Northern Mariana Islands (CNMI) (after November 4, 1986). The birth record may be issued by the state, Commonwealth, territory, or local jurisdiction. The individual may also be collectively naturalized under federal regulations. A cross match with the Massachusetts Registry of Vital Statistics that documents a record of birth A Certification of a Report of Birth issued to U.S. citizens who were born outside the U.S. A Report of Birth Abroad of a U.S. Citizen Certification of birth A U.S. Citizen ID card A Northern Mariana Identification Card issued to a collectively naturalized citizen who was born in the CNMI before November 4, 1986 A final adoption decree showing the child s name and U.S. place of birth (if adoption is not final, a statement from a state-approved adoption agency that shows the child s name and U.S. place of birth) Evidence of U.S. civil service employment before June 1, 1976 An official U.S. military record showing a U.S. place of birth A data match with the Systematic Alien Verification for Entitlements (SAVE) Program or any other process established by the Department of Homeland Security (DHS) to prove an individual is a citizen Documentation that a child meets the requirements of section 101 of the Child Citizenship Act of 2000 (8 U.S.C. 1431) Medical records, including, but not limited to, hospital, clinic, or doctor records, or admission papers from a nursing facility, skilled care facility, or other institution that indicate a U.S. place of birth Life, health, or other insurance record that indicates a U.S. place of birth An official religious record recorded in the U.S. showing that the birth occurred in the U.S. School records, including preschool, Head Start, and day care, showing the child s name and U.S. place of birth Federal or state census record showing U.S. citizenship or a U.S. place of birth If an individual does not have one of the documents listed in 130 CMR , he or she may submit an affidavit signed by another individual, under penalty of perjury, who can reasonably attest to the individual s citizenship, and that contains the individual s name, date of birth, and place of U.S. birth. The affidavit does not have to be notarized.

43 PLUS proof of Identity Only The following documents are acceptable proof of identity, provided this documentation has a photograph or other identifying information including, but not limited to, name, age, sex, race, height, weight, eye color, or address. Identity documents listed at 8 CFR 274a.2(b) (1)(v)(B)(1), except a driver s license issued by a Canadian government authority A driver s license issued by a state or territory A school identification card A U.S. military card or draft record An identification card issued by the federal, state, or local government A military dependent s identification card A U.S. Coast Guard Merchant Mariner card For children younger than age 19, a clinic, doctor, hospital, or school record, including preschool or day care records Two documents containing consistent information that confirms an applicant s identity. These documents include, but are not limited to: employer identification cards high school and college diplomas (including high school equivalency diplomas) marriage certificates divorce decrees property deeds or titles a pay stub from a current employer with the applicant s name and address preprinted, dated within 60 days of the application census proof containing the applicant s name and address, dated not more than 12 months before the date of the application a pension or retirement statement from a former employer or pension fund stating the applicant s name and address, dated within 12 months of the application tuition or student loan bill containing the applicant s name and address, dated not more than 12 months before the date of the application utility bill, cell phone bill, credit card bill, doctor s bill, or hospital bill containing applicant s name and address, dated not more than 60 days before the date of the application Visit us online at MAhealthconnector.org valid homeowner s, renter s, or automobile insurance policy with preprinted address, dated not more than 12 months before the date of the application, or a bill for this insurance with preprinted address, dated not more than 60 days before the date of the application lease dated not more than 12 months before the date of the application, or home mortgage identifying applicant and address employment proved by W-2 forms or other documents showing the applicant s name and address submitted by the employer to a government agency as a consequence of employment A finding of identity from a federal or state agency, including, but not limited to, a public assistance, law enforcement, internal revenue, tax bureau, or corrections agency, if the agency has proved and certified the identity of the individual A finding of identity from an Express Lane agency, as defined in section 1902(e)(13)(F) of the Social Security Act If the applicant does not have any document specified in the first three main bullets above, and identity is not proved through the fourth and fifth main bullets above, the applicant may submit an affidavit signed, under penalty of perjury, by another person who can reasonably attest to the applicant s identity. This affidavit must contain the applicant s name and other identifying information establishing identity, as described in the first main bullet above. This affidavit does not have to be notarized. 41

44 42 SECTION 10 Where to get help Topic: the status of your application member eligibility information to process case and examples of acceptable forms of proof general eligibility and MassHealth benefits enrollment into a health plan interpreter services how to get forms of proof MassHealth and Children s Medical Security Plan premiums questions about the voter registration process and help filling out the Voter Registration Form how to get applications and forms Call: MassHealth Enrollment Center (TTY: for people who are deaf, hard of hearing, or speech disabled) selfservices available 24 hours/7 days a week MassHealth Customer Service TTY: MassHealth Enrollment Center or MassHealth Customer Service (See phone numbers above.) estate recovery Benefit Coordination/Third Party Liability Children s Medical Security Plan (CMSP) ( for questions about covered services and finding a provider) MassHealth appeals - fair hearings Board of Hearings 100 Hancock St., 6th Floor, Quincy, MA or ( fax) Medicare prescription drug coverage MEDICARE ( ) TTY: Massachusetts Health Connector reporting changes information about enrollment in health plans, other program information, and appeals information to report member or provider fraud Health Safety Net grievances with HSN MA-ENROLL ( ) TTY: ( FRAUD-0) Health Safety Net Customer Service Center Health Safety Net Office, Attn.: HSN Grievances 100 Hancock St., 6th Floor Quincy, MA 02171

45 Visit us online at MAhealthconnector.org 43 Topic: to apply for an SSN for applicants and members with disabilities who need accommodations Legal services Call: Social Security Administration (SSA) MassHealth Disability Accommodation Ombudsman 100 Hancock Street, 6th Floor Quincy, MA TTY: A list of free and low-cost legal services is available on the MassHealth web site at If you would like this list in print form, call the MassHealth Customer Service Center at TTY:

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47 IMPORTANT INFORMATION ABOUT VOTER REGISTRATION Dear Applicant or Member: The National Voter Registration Act of 1993 requires MassHealth to give you the opportunity to register to vote. Your decision to register to vote will not affect your eligibility for benefits. If you would like a mail-in voter registration form sent to you, please call the MassHealth Customer Service Center at (TTY: for people who are deaf, hard of hearing, or speech disabled). When you get the form, fill it out and send it to your city or town hall. If you have any questions about the voter registration process, or if you need help filling out the form, call one of the telephone numbers listed above. Remember: You will not be registered to vote until you send the filled-out voter registration form to your local city or town hall. Your local election department will let you know in writing when your voter registration has been processed. If you do not get written notification within a reasonable time, contact your local city or town hall election department for more information. VOTE-3 (Rev. 03/15) Commonwealth of Massachusetts Executive Office of Health and Human Services MassHealth Elder Affairs Prescription Advantage Program Persons who are not getting prescription drug benefits under MassHealth or Medicare, who are either under age 65 and disabled, or are aged 65 or older, and want information about help with prescription drug costs, may call the Elder Affairs Prescription Advantage Program at AGE-INFO or (TTY: for people who are deaf, hard of hearing, or speech disabled).

48 Important! If you need an interpreter or translation help with any MassHealth notice or form, or if you want a booklet/guide in your language, or if you have any questions about MassHealth, please call the MassHealth Customer Service Center at (TTY: for people who are deaf, hard of hearing, or speech disabled). MassHealth does not discriminate on the basis of national origin. [ITF Rev. 10/12] This booklet is also available in braille and large-print editions. To get a copy, please call the MassHealth Customer Service Center at (TTY: for people who are deaf, hard of hearing, or speech disabled). ACA-1 (Rev. 03/15)